By Gretchen C. Van Benthuysen |
There is a lot happening in the world of ovarian cancer that is helping doctors to better understand the disease and how to manage it.
Advancements in diagnosis and treatment are joining a holistic approach, relationship-based, care model for patients and families at the Memorial Sloan Kettering (Cancer Center) Monmouth at 480 Red Hill Road in Middletown.
Called the “silent killer,” as cancer symptoms rarely surface in the early stages, patients and doctors also may misinterpret pain in the abdomen or an irritable bowel as gastrointestinal problems.
The American Cancer Society (ACS) estimates for ovarian cancer in the United States for 2018 are: about 22,240 women will receive a new diagnosis and about 14,070 women will die from it.
But the rate at which women are diagnosed with ovarian cancer, which mainly develops in older women (about half are 63 or older), has been slowly falling during the past 20 years, according to the ACS.
Jason A. Konner, M.D., chief of medical oncology at MSK Monmouth, and Elizabeth Jewell, M.D., director of surgery for both MSK Monmouth and MSK Basking Ridge and director of MSK Monmouth operating rooms, recently discussed advancements in their fields, particularly the emergence of immunotherapy and its importance in cancer treatment.
Konner, Little Silver, treats cervical, uterine (endometrial) and ovarian cancers. Jewell, Fair Haven, is a gynecologic oncologist specializing in caring for women with cancers of the ovary, uterus, cervix and vulva. Both see patients locally and commute each week to Manhattan for meetings and patients.
One thing research and clinical trials have discovered is that 70 percent of ovarian cancers start in the fallopian tubes with the cancer cells traveling to the ovaries, Konner said.
“The more we understand, the bigger the impact on treatment,” he explained. “So now we can remove only the fallopian tubes and leave the ovaries to avoid early menopause.”
But what if the cancer has spread to the ovaries?
“Immunotherapy has blossomed in the last 10 years and become a component in standard care for a variety of cancers, ovarian as well as melanoma and lung cancers,” he explained.
Konner was given a diagnosis of stage II melanoma the day after he graduated from college. Being able to tell patients he is a cancer survivor, he said, helps them hear the news and be positive.
Immunotherapy works in different ways: some boosts the body’s immune system, others stimulate the immune system to work harder or smarter to attack cancer cells.
“Immunotherapy trials have shown varying degrees of activity in ovarian, endometrial, and cervix cancers,” Konner said. “A key attribute of cancer cells in the body is they can hide in plain sight.
“Cells may have proteins on their surface that suppresses the immune response to cancer,” he said. “Now that we understand the biology of these processes, targeted drugs have been designed that can unmask some of these cancer cells for the immune system to fight.”
“There can be side effects when the immune system attacks normal cells,” he added. “It’s a balance we have in all treatments: risk vs. benefit. In most patients the risk is low, lower than chemotherapy, which can weaken the immune system.”
The Holy Grail, Konner said, is to identify mutations in the fallopian tubes before cancer cells deliver toxic fluids to the ovaries and cause cancer.
He said women with a family history of ovarian cancer should get tested for the BRCA1 and BRCA2 breast cancer genes. Mutated forms of these genes are believed to be responsible for about half of the cases of inherited breast cancer, especially those that occur in younger women.
“It will help women make practical decisions about prevention,” he said.
Doctors can predict the average outcome of a large group of women, but it’s impossible to predict one woman’s future.
Removing the ovaries early will result in a lack of estrogen and early menopause possibly leading to such problems as osteoporosis and cardiovascular disease. The ovaries can be removed later at an older age.
If surgery is needed, Jewell said advances have been made that prioritize the quality of life and preserve fertility.
For example, she said, a woman with uterine or cervical cancer would routinely have all the lymph nodes in her pelvis removed. (Lymph nodes are located in groups, and each group drains a specific area of your body.)
“We don’t do that now,” she explained. “Instead, I use a fluorescent dye to find the most important, the sentinel lymph nodes, and target just the few most likely to contain cancer.
“Such more conservative operations reduce complications and long-term problems, such as lymphedema of the legs (fluid buildup).”
Also, she said, women with aggressive early stage cervical cancer previously would have their entire uterus and cervix removed. Now a trachelectomy to remove just the cervix, but save the uterus, may be performed on younger women who desire children.
“We do a lot each year,” Jewell said. “ More than 100 babies have been born in the last decade by women who had cervical cancer.”
Another way MSK manages ovarian cancer, which can spread to the intestines, diaphragm, pancreas and pelvic areas, is to remove as much as possible to improve survival rates.
“If you can get all the cancer out, chemotherapy doesn’t have to work as hard and there is less resistance to drugs,” she explained. “If you are starting with a smaller amount of cancer, you have a better outcome.”
These radical surgeries that include complete removal of disease in the upper abdomen and the pelvis have resulted in years of improvement of survival. Few drugs have demonstrated such a dramatic impact on survival.
In early uterine and early cervical cancer, we now can be less aggressive,” Jewell said. “We used to do radical removal of the lymph nodes. We are doing less radical surgeries now. We focus on survival and that includes quality of life.
“We are constantly improving techniques,” Jewell said. “For instance, in clinical trials we heated the chemo. We wanted to know if the absorption was better so it killed more cancer cells.”
This article was first published in the Feb. 1-8, 2018 print edition of The Two River Times.
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